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Yang X, Chen S, Song H, Shu R, Wang J, Wang G, Liu P, Li M, Wu L, Li N, Cui L, Wu S. Association between cardiac conduction block and cardiovascular disease and all-cause mortality: The kailuan study. Int J Cardiol 2024; 399:131666. [PMID: 38141733 DOI: 10.1016/j.ijcard.2023.131666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Although bundle branch block and atrioventricular block are recognized to be association with cardiovascular disease (CVD) and mortality, the relationship between cardiac conduction block (CCB) and both CVD and all-cause mortality has yet to be explored. AIMS To explore the relationship between CCB and CVD and all-cause mortality. METHODS AND RESULTS We included 145,805 subjects (mean age 49.7 years, 81.2% males) from the kailuan study. CCB was diagnosed through a 12‑lead electrocardiograph (ECG). Mortality and CVD events were ascertained through multiple sources, including a municipal social insurance institution, hospital records, death certificates, and regular active follow-ups. After a mean follow-up of 12.5 years, 18,301 cases developed all-cause mortality. After excluding 4443 subjects with CVD presence at baseline, 13,208 cases of CVD occurred among the 141,362 study subjects during follow-up. Compared with non-CCB group, the cumulative incidence of CVD and all-cause mortality for CCB group was 18.38% VS 12.14% and 33.45% VS 14.18%, respectively. The multivariable-adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) with CCB group were 1.25(1.17-1.34) for CVD, and 1.31(1.25-1.38) for all-cause mortality. Additionally, there were generally stronger associations for CCB with all-cause mortality and CVD in younger participants compared with their older counterparts (Ps-interaction <0.001). CONCLUSION CCB can increase the risk of CVD and all-cause mortality in the general population. Our findings highlight the importance of strategies for preventing CCB to reduce the risk of CVD and mortality.
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Affiliation(s)
- Xuemei Yang
- Department of Rheumatic Disease, Kailuan General Hospital, Tangshan, Hebei, China; Graduate school, North China University of Science and Technology, Tangshan, Hebei, China
| | - Shuohua Chen
- Department of Cardiology, Kailuan General Hospital, Tangshan, Hebei, China
| | - Haicheng Song
- Department of Rheumatic Disease, Kailuan General Hospital, Tangshan, Hebei, China
| | - Rong Shu
- Department of Rheumatic Disease, Kailuan General Hospital, Tangshan, Hebei, China
| | - Jierui Wang
- Department of Rheumatic Disease, Kailuan General Hospital, Tangshan, Hebei, China
| | - Guodong Wang
- Department of Cardiology, Kailuan General Hospital, Tangshan, Hebei, China
| | - Peipei Liu
- School of Public Health, North China University of Science and Technology, Tangshan, Hebei, China
| | - Man Li
- Graduate school, North China University of Science and Technology, Tangshan, Hebei, China
| | - Lili Wu
- Department of Cardiology, Shanghai Songjiang District Central Hospital, Shanghai, China
| | - Na Li
- Department of Rheumatic Disease, Kailuan General Hospital, Tangshan, Hebei, China
| | - Liufu Cui
- Department of Rheumatic Disease, Kailuan General Hospital, Tangshan, Hebei, China.
| | - Shouling Wu
- Department of Cardiology, Kailuan General Hospital, Tangshan, Hebei, China.
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Lanjewar CP, Shah BS, Sabnis GR, Sharma A, Kumar D. The 'qRBBB myocardial infarction': Unwrapping an old enigma. Indian Heart J 2024; 76:57-59. [PMID: 38199561 PMCID: PMC10943532 DOI: 10.1016/j.ihj.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 12/11/2023] [Accepted: 01/06/2024] [Indexed: 01/12/2024] Open
Abstract
This single-center, prospective, observational study was conducted at a tertiary-care center over a span of two years. Patients presenting with acute Anterior-Wall STEMI were included as a study population. The subgroups included qRBBB pattern on ECG and non-qRBBB group. Among 1128 patients included in the study, 100 (11.28 %) patients presented with qRBBB pattern. Increased risk of cardiogenic shock, increased hospital-stay, a higher Killip class on presentation, high incidence of recanalized IRA, remarkably depressed LVEF were significantly associated with qRBBB-MI, which is a menacing form of ACS that leads not only to a high mortality but also to a long-term morbidity.
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Affiliation(s)
- Charan P Lanjewar
- King Edward Memorial Hospital and Seth G.S. Medical College, Mumbai, India.
| | - Bhavik S Shah
- King Edward Memorial Hospital and Seth G.S. Medical College, Mumbai, India
| | - Girish R Sabnis
- King Edward Memorial Hospital and Seth G.S. Medical College, Mumbai, India
| | - Achal Sharma
- King Edward Memorial Hospital and Seth G.S. Medical College, Mumbai, India
| | - Dhiraj Kumar
- King Edward Memorial Hospital and Seth G.S. Medical College, Mumbai, India
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The Differences in Clinical Characteristic and Outcomes of New Onset Typical versus Atypical Right Branch Bundle Block in Acute Myocardial Infarction. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:4620881. [PMID: 36105442 PMCID: PMC9452991 DOI: 10.1155/2022/4620881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/01/2022] [Accepted: 08/01/2022] [Indexed: 11/22/2022]
Abstract
Objective The purpose of this study is to explore the clinical characteristics and estimate the new-onset atypical right branch bundle block (ATRBBB) predictive value in short-term and long-term mortality by comparing the typical right branch bundle block (TRBBB) subset in acute myocardial infarction (AMI) patients. Methods A total of 224 AMI patients combined with new onset RBBB who received primary coronary angiography were included, being admitted to Henan Provincial People's Hospital in China from July 2010 to June 2021. Patients were divided into typical RBBB group (n = 104) and atypical RBBB group (n = 120). The differences in clinical characteristics between the two groups were analyzed. Logistic and Cox regression analysis were performed to identify independent predictors of in-hospital Major Adverse Cardiovascular Events (MACE). Result The ATRBBB group had a higher proportion of smoking and alcohol consumption, higher body mass index, worse cardiac function (killip ≧ II proportion), higher peak value of CK-MB, lower LVEF%, longer total ischemia time, higher proportion of LAD (left anterior descending coronary artery) occlusion, and multivessel lesions, compared to the TRBBB group. The ATRBBB group had a higher proportion of in-hospital MACE and 1-year all-cause mortality compared to the TRBBB group. ATRBBB was an independent predictor of in-hospital MACE and 1-year mortality in patients with AMI combined with new onset RBBB. Conclusions ATRBBB group had more serious clinical symptoms and clinical prognosis. New ATRBBB is an independent predictor of in-hospital MACE and 1-year death in patients with AMI combined with RBBB. If the infarct-related vessel was opened immediately, the evolution of TRBBB to ATRBBB may be avoided, leading to a better prognosis.
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2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Translation of the document prepared by the Czech Society of Cardiology. COR ET VASA 2022. [DOI: 10.33678/cor.2022.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJ, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM. Grupo de trabajo sobre estimulación cardiaca y terapia de resincronización cardiaca de la Sociedad Europea de Cardiología (ESC). Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJS, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM, Leyva F, Linde C, Abdelhamid M, Aboyans V, Arbelo E, Asteggiano R, Barón-Esquivias G, Bauersachs J, Biffi M, Birgersdotter-Green U, Bongiorni MG, Borger MA, Čelutkienė J, Cikes M, Daubert JC, Drossart I, Ellenbogen K, Elliott PM, Fabritz L, Falk V, Fauchier L, Fernández-Avilés F, Foldager D, Gadler F, De Vinuesa PGG, Gorenek B, Guerra JM, Hermann Haugaa K, Hendriks J, Kahan T, Katus HA, Konradi A, Koskinas KC, Law H, Lewis BS, Linker NJ, Løchen ML, Lumens J, Mascherbauer J, Mullens W, Nagy KV, Prescott E, Raatikainen P, Rakisheva A, Reichlin T, Ricci RP, Shlyakhto E, Sitges M, Sousa-Uva M, Sutton R, Suwalski P, Svendsen JH, Touyz RM, Van Gelder IC, Vernooy K, Waltenberger J, Whinnett Z, Witte KK. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Europace 2022; 24:71-164. [PMID: 34455427 DOI: 10.1093/europace/euab232] [Citation(s) in RCA: 137] [Impact Index Per Article: 68.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJS, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J 2021; 42:3427-3520. [PMID: 34455430 DOI: 10.1093/eurheartj/ehab364] [Citation(s) in RCA: 840] [Impact Index Per Article: 280.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Galcerá-Jornet E, Consuegra-Sánchez L, Galcerá-Tomás J, Melgarejo-Moreno A, Gimeno-Blanes JR, Jaulent-Huertas L, Wasniewski S, de Gea-García J, Vicente-Gilabert M, Padilla-Serrano A. Association between new-onset right bundle branch block and primary or secondary ventricular fibrillation in ST-segment elevation myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:918-925. [PMID: 33993235 DOI: 10.1093/ehjacc/zuab026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 04/08/2021] [Indexed: 11/13/2022]
Abstract
AIMS New-onset right bundle branch block (RBBB) in myocardial infarction (MI) is often associated with ventricular fibrillation (VF) but the nature of this relationship has not been determined. METHODS AND RESULTS Between 1998 and 2014, among other data, incidence and duration of RBBB and VF occurrence were prospectively collected in 5301 patients with ST-segment elevation MI (STEMI) admitted to two University Hospitals in Murcia (Spain). Multinomial adjusted logistic regression analyses were used to examine the association between RBBB, attending to its duration, and VF according to its primary VF (PVF) or secondary VF (SVF) character. Among 284 (5.4%) patients with new-onset RBBB, 158 were transient and 126 permanent. VF occurred in 339 (6.4%) patients, 201 PVF and 138 SVF, documented within the first 2 h of symptoms-onset in 78% and 60%, respectively. New-onset RBBB was more frequent in PVF (11.4%) and SVF (20.3%), than in non-VF (4.7%). Transient RBBB incidence was higher in PVF (9.0%) and SVF (9.4) than in non-VF (2.6%), whereas permanent RBBB was higher in SVF (10.9%) than PVF (2.5%) and non-VF (2.1%). New-onset RBBB 1.83 [95% confidence interval (CI): 1.07-3.11] and new-onset transient RBBB 2.39 (95% CI: 1.32-4.32) were independently associated with PVF. New-onset 3.03 (95% CI: 1.83-5.02), transient 2.40 (95% CI: 1.27-4.55), and permanent 2.99 (95% CI: 1.52-5.86) RBBB were independently associated with SVF. CONCLUSION New-onset RBBB and VF in STEMI are independently associated and show particularities based on the duration of the conduction disturbance and/or the primary or secondary character of the arrhythmia.
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Affiliation(s)
- Emilio Galcerá-Jornet
- Department of Cardiology, Hospital de Denia, Av. Marina Alta, s/n, 03700 Dénia, Alicante, Spain
| | - Luciano Consuegra-Sánchez
- Department of Cardiology, Hospital Universitario Santa Lucía de Cartagena, Calle Minarete, s/n, 30202 Cartagena, Murcia, Spain
| | - José Galcerá-Tomás
- Coronary Care Unit, Department of Intensive Care Medicine, Hospital Clínico Universitario Virgen de la Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120 El Palmar, Murcia, Spain
| | - Antonio Melgarejo-Moreno
- Coronary Care Unit, Department of Intensive Care Medicine, Hospital Universitario Santa Lucía de Cartagena, Calle Minarete, s/n, 30202 Cartagena, Murcia, Spain
| | - Juan Ramón Gimeno-Blanes
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120 El Palmar, Murcia, Spain
| | - Leticia Jaulent-Huertas
- Department of Cardiology, Hospital Universitario Santa Lucía de Cartagena, Calle Minarete, s/n, 30202 Cartagena, Murcia, Spain
| | - Samantha Wasniewski
- Department of Cardiology, Hospital Universitario Santa Lucía de Cartagena, Calle Minarete, s/n, 30202 Cartagena, Murcia, Spain
| | - José de Gea-García
- Coronary Care Unit, Department of Intensive Care Medicine, Hospital Clínico Universitario Virgen de la Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120 El Palmar, Murcia, Spain
| | - Marta Vicente-Gilabert
- Emergency Department, Hospital Clínico Universitario Virgen de la Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120 El Palmar, Murcia, Spain
| | - Antonio Padilla-Serrano
- Coronary Care Unit, Department of Intensive Care Medicine, Hospital Clínico Universitario Virgen de la Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120 El Palmar, Murcia, Spain
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Birnbaum Y, Nikus K, Atar D, Jneid H. Is RBBB the new LBBB? Are we going to repeat the same mistakes? J Electrocardiol 2021; 65:34-36. [PMID: 33477070 DOI: 10.1016/j.jelectrocard.2020.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Yochai Birnbaum
- The Section of Cardiology, The Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America.
| | - Kjell Nikus
- Heart Center, Tampere University, Hospital and Faculty of Medicine, Finland; Faculty of Medicine, Tampere University, Finland
| | - Dan Atar
- Dept. of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway; Institute of Clinical Sciences, Norway
| | - Hani Jneid
- The Section of Cardiology, The Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America
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Electrocardiographic Predictors of Mortality in Acute Anterior Wall Myocardial Infarction With Right Bundle Branch Block and Right Precordial Q-Waves (qRBBB). Can J Cardiol 2020; 36:1764-1769. [DOI: 10.1016/j.cjca.2020.02.065] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/30/2020] [Accepted: 02/05/2020] [Indexed: 01/16/2023] Open
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Klein A, Baranchuk A. Identification of High-Risk Patients Based on Electrocardiogram During Acute Anterior ST-Elevation Myocardial Infarction: The qRBBB Pattern. Can J Cardiol 2020; 36:1708-1709. [DOI: 10.1016/j.cjca.2020.04.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/24/2020] [Accepted: 04/24/2020] [Indexed: 11/27/2022] Open
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Do DH, Yang JJ, Kuo A, Bradfield JS, Hu X, Shivkumar K, Boyle NG. Electrocardiographic right ventricular strain precedes hypoxic pulseless electrical activity cardiac arrests: Looking beyond pulmonary embolism. Resuscitation 2020; 151:127-134. [PMID: 32360319 DOI: 10.1016/j.resuscitation.2020.04.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/26/2020] [Accepted: 04/16/2020] [Indexed: 01/22/2023]
Abstract
AIM The role of the right ventricle (RV) in pulseless electrical activity (PEA) is poorly defined outside of pulmonary embolism. We aimed to (1) describe the continuous electrocardiographic (ECG) manifestations of RV strain (RVS) preceding PEA/Asystole in-hospital cardiac arrest (IHCA), and (2) determine the prevalence and clinical causes of RVS in PEA/Asystole IHCA. METHODS In this retrospective cross-sectional study, we evaluated 140 patients with continuous ECG data preceding PEA/Asystole IHCA. We iteratively defined the RVS continuous ECG pattern using the development cohort (93 patients). Clinical cause determination was blinded from ECG analysis in the validation cohort (47 patients). RESULTS The overall cohort had mean age 62.1 ± 17.1 years, 70% return of spontaneous circulation and 30% survival to discharge. RVS continuous ECG pattern was defined as progressive RV depolarization delay in lead V1 with at least one supporting finding of RV ischaemia or right axis deviation. Using this criterion, 66/140 (47%) cases showed preceding RVS. In patients with RVS, no pulmonary embolism was found in 9/13 (69%) autopsies and 8/10 (80%) CT chest angiograms. The positive and negative predictive value of RVS pattern for diagnosing a respiratory cause of PEA/Asystole in the validation cohort was 81% [95% CI 64-98%] and 58% [95% CI 36-81%], respectively. CONCLUSION RVS continuous ECG pattern preceded 47% of PEA/Asystole IHCA and is predictive of a respiratory cause of cardiac arrest, not just pulmonary embolism. These suggest that rapid elevations in pulmonary pressures and resultant RV failure may cause PEA in respiratory failure.
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Affiliation(s)
- Duc H Do
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.
| | - Jason J Yang
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Alan Kuo
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Xiao Hu
- Duke University School of Nursing, Duke University, Durham, NC, United States
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Noel G Boyle
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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Tolppanen H, Javanainen T, Sans-Rosello J, Parenica J, Nieminen T, Pavlusova M, Masip J, Köber L, Banaszewski M, Sionis A, Spinar J, Harjola VP, Jurkko R, Lassus J. Prevalence, Temporal Evolution, and Impact on Survival of Ventricular Conduction Blocks in Patients With Acute Coronary Syndrome and Cardiogenic Shock. Am J Cardiol 2018; 122:199-205. [PMID: 29778237 DOI: 10.1016/j.amjcard.2018.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 03/24/2018] [Accepted: 04/02/2018] [Indexed: 10/17/2022]
Abstract
Changes in QRS duration and pattern are regarded to reflect severe ischemia in acute coronary syndromes (ACS), and ventricular conduction blocks (VCBs) are recognized high-risk markers in both ACS and acute heart failure. Our aim was to evaluate the prevalence, temporal evolution, association with clinical and angiographic parameters, and impact on mortality of VCBs in ACS-related cardiogenic shock (CS). Data of 199 patients with ACS-related CS from a prospective multinational cohort were evaluated with electrocardiogram data from baseline and day 3. VCBs including left or right bundle branch block, right bundle branch block and hemiblock, isolated hemiblocks, and unspecified intraventricular conduction delay were assessed. Fifty percent of patients had a VCB at baseline; these patients were older, had poorer left ventricular function and had more often left main disease compared with those without VCB. One-year mortality was over 2-fold in patients with VCB compared with those without VCB (68% vs 32%, p<0.001). All types of VCBs at baseline were associated with increased mortality, and the predictive value of a VCB was independent of baseline variables and coronary angiography findings. Interestingly, 37% of the VCBs were transient, i.e., disappeared before day 3. However, 1-year mortality was much higher in these patients (69%) compared to patients with persistent (38%) or no VCB (15%, p<0.001). Indeed, a transient VCB was a strong independent predictor of 1-year mortality. In conclusion, our findings propose that any VCB in baseline electrocardiogram, even if transient, identifies very early patients at particularly high mortality risk in ACS-related CS.
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Wang J, Luo H, Kong C, Dong S, Li J, Yu H, Chu Y. Prognostic value of new-onset right bundle-branch block in acute myocardial infarction patients: a systematic review and meta-analysis. PeerJ 2018; 6:e4497. [PMID: 29576967 PMCID: PMC5853603 DOI: 10.7717/peerj.4497] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 02/22/2018] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Patients with acute myocardial infarction (AMI) and bundle-branch block have poor prognoses. The new European Society of Cardiology guideline suggests a primary percutaneous coronary intervention strategy when persistent ischemic symptoms occur in patients with persistent ischemic symptoms and right bundle-branch block (RBBB), but the level of evidence is not high. In fact, the presence of RBBB may lead to the misdiagnosis of transmural ischemia and mask the early diagnosis of ST-elevation myocardial infarction. Moreover, new-onset RBBB is occasionally caused by AMI. Our study aims to investigate the prognostic value of new-onset RBBB in AMI. METHODS AND RESULTS We conducted a meta-analysis of studies to evaluate the prognostic value of RBBB in AMI patients. Of 914 primary records, five studies and 874 MI patients were included for meta-analysis. Compared with previous RBBB, AMI patients with new-onset RBBB had a higher risk of long-term mortality (RR, 1.66, 95% CI [1.31-2.09], I2 = 0.0%, p = 0.000, n = 2), ventricular arrhythmia (RR, 4.86, 95% CI [2.10-11.27], I2 = 0.0%, p = 0.000, n = 3), and cardiogenic shock (RR, 2.76, 95% CI [1.66-4.59], I2 = 0.0%, p = 0.000, n = 3), but a lower risk of heart failure (RR, 0.66, 95% CI [0.52-0.85], I2 = 2.50%, p = 0.001, n = 4). Compared with AMI patients with new-onset permanent RBBB, patients with new-onset transient RBBB had a lower risk of short-term mortality (RR, 0.20, 95% CI [0.11-0.37], I2 = 44.1%, p = 0.000, n = 4). CONCLUSION New-onset RBBB is likely to increase long-term mortality, ventricular arrhythmia, and cardiogenic shock, but not heart failure in AMI patients. AMI patients with new-onset transient RBBB have a lower risk of short-term mortality than those with new-onset permanent RBBB. Revascularization therapies should be considered when persistent ischemic symptoms occur in patients with RBBB, especially new-onset RBBB.
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Affiliation(s)
- Juntao Wang
- Department of Cardiology, Zhengzhou University People’s Hospital, Zhengzhou, China
| | - Hongxing Luo
- Department of Cardiology, Zhengzhou University People’s Hospital, Zhengzhou, China
| | - Chunling Kong
- Department of Cardiology, Zhengzhou University People’s Hospital, Zhengzhou, China
| | - Shujuan Dong
- Department of Cardiology, Henan Province People’s Hospital, Zhengzhou, China
| | - Jingchao Li
- Department of Cardiology, Henan Province People’s Hospital, Zhengzhou, China
| | - Haijia Yu
- Department of Cardiology, Henan Province People’s Hospital, Zhengzhou, China
| | - Yingjie Chu
- Department of Cardiology, Zhengzhou University People’s Hospital, Zhengzhou, China
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Li J, Li X, Dong S, Yang Y, Chu Y. Clinical characteristics and value in early reperfusion therapy for new onset right bundle branch block in patients with acute myocardial infarction. Exp Ther Med 2017; 15:2620-2626. [PMID: 29467855 DOI: 10.3892/etm.2017.5661] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 09/20/2017] [Indexed: 01/03/2023] Open
Abstract
The value of the right bundle branch block (RBBB) in the treatment of acute myocardial infarction remains unclear. Studies on the RBBB may significantly influence the treatment of acute myocardial infarction. A total of 845 patients with acute myocardial infarction who underwent primary coronary angiography at Henan Provincial People's Hospital were analyzed. Higher peak enzyme levels, a higher ratio of Killip ≥II and closer proximal occlusion of infarct-related artery (IRA) were observed in patients with RBBB compared with those without. The ratio of TIMI flow 0/1 of IRA and ratio of received primary percutaneous coronary intervention (PCI) to IRA in the RBBB group were significantly higher compared with those in the left (L) BBB or no BBB groups. The in-hospital major adverse cardiac events (MACE) incidence in the RBBB group was higher compared with that in the no BBB group, but there was no significant difference between the RBBB and LBBB groups. Logistic regression revealed that proximal occlusion and TIMI flow 0/1 of IRA were predictive factors of RBBB. Cox regression analysis identified RBBB [risk ratio (RR), 4.682; P<0.001] and LBBB (RR, 3.687; P<0.001) as independent predictors of in-hospital MACE. The cumulative one-year survival rate in the RBBB group was significantly lower than those in the no BBB group (P<0.05) and the LBBB group (P<0.05). Similar to the guidelines regarding new onset of LBBB, new onset RBBB should be considered as a standard indicator for reperfusion therapy; as RBBB is associated with more severe symptoms, and higher incidents of complete occlusion of IRA and primary PCI treatment compared with LBBB.
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Affiliation(s)
- Jingchao Li
- Department of Cardiology, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, P.R. China
| | - Xiaodong Li
- Department of Radiology, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, P.R. China
| | - Shujuan Dong
- Department of Cardiology, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, P.R. China
| | - Yapan Yang
- Department of Cardiology, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, P.R. China
| | - Yingjie Chu
- Department of Cardiology, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, P.R. China
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Held N, Little N, Krantz MJ, Stauffer BL. Refractory Cardiogenic Shock from Right Ventricular Infarction Successfully Managed with Inhaled Epoprostenol. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:271-275. [PMID: 28298620 PMCID: PMC5363174 DOI: 10.12659/ajcr.901975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Recognition and appropriate management of right ventricular (RV) infarction is essential, as RV injury increases mortality and substantially alters management during acute coronary syndrome. We report a case of RV infarction presenting with new right bundle branch block (RBBB), and therapeutic use of inhaled epoprostenol to reduce RV afterload and augment cardiac output during refractory cardiogenic shock. CASE REPORT A 53-year-old male presented to our institution in ventricular fibrillation with subsequent development of RBBB in the setting of proximal right coronary artery occlusion. Following percutaneous coronary intervention, the patient developed severe RV dysfunction with refractory cardiogenic shock. This was successfully managed with inhaled epoprostenol with normalization of right ventricular systolic function. CONCLUSIONS Although typically associated with anterior myocardial infarction, new RBBB should be recognized as a potential presenting sign of acute RV infarction. The use of inhaled epoprostenol in the setting of RV infarction has not been previously described, but it may augment right ventricular cardiac output via pulmonary vasodilatation.
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Affiliation(s)
- Natalie Held
- School of Medicine, University of Colorado, Aurora, CO, USA
| | | | - Mori J Krantz
- School of Medicine, University of Colorado, Aurora, CO, USA.,Department of Internal Medicine - Cardiology, Denver Health Medical Center, Denver, CO, USA
| | - Brian L Stauffer
- School of Medicine, University of Colorado, Aurora, CO, USA.,Department of Internal Medicine - Cardiology, Denver Health Medical Center, Denver, CO, USA
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Left ventricular ejection fraction and mortality in patients with ST-elevation myocardial infarction and bundle branch block. Coron Artery Dis 2016; 28:232-238. [PMID: 27906703 DOI: 10.1097/mca.0000000000000456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aim of our study is to assess the effect of bundle branch block (BBB) on mortality and left ventricular ejection fraction (LVEF) in ST-elevation myocardial infarction (STEMI) patients treated in the current era of percutaneous reperfusion therapy. PATIENTS AND METHODS In this retrospective cohort study, a total of 1123 STEMI patients treated in the University Medical Center Groningen from January 2011 until May 2013 were included. The follow-up duration was 2-4 years. Transthoracic echocardiography was performed within 2 weeks after STEMI. RESULTS In total, 23 (2.0%) patients presented with left BBB and 49 (4.4%) patients presented with right BBB. Two-year mortality after STEMI was 25.0% (n=18) in patients with BBB and 9.2% (n=97, P<0.001) in patients without BBB. Patients with BBB had more frequently a severely reduced LVEF (<30%) [20.0% (n=6) compared with 4.2% (n=21), P=0.002] and less frequently a normal LVEF [16.7% (n=5) compared with 35.7% (n=179), P=0.046]. After multivariable analysis, BBB did not remain an independent predictor of mortality, but was an independent predictor of reduced LVEF. CONCLUSION The presence of a BBB was an independent predictor of a reduced LVEF. However, we found no effect of BBB on 2-year mortality in the current era of percutaneous reperfusion therapy.
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Grand J, Thomsen JH, Kjaergaard J, Nielsen N, Erlinge D, Wiberg S, Wanscher M, Bro-Jeppesen J, Hassager C. Prevalence and Prognostic Implications of Bundle Branch Block in Comatose Survivors of Out-of-Hospital Cardiac Arrest. Am J Cardiol 2016; 118:1194-1200. [PMID: 27553102 DOI: 10.1016/j.amjcard.2016.07.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/21/2016] [Accepted: 07/21/2016] [Indexed: 11/29/2022]
Abstract
This study reports the prevalence and prognostic impact of right bundle branch block (RBBB) and left bundle branch block (LBBB) in the admission electrocardiogram (ECG) of comatose survivors of out-of-hospital cardiac arrest (OHCA). The present study is part of the predefined electrocardiographic substudy of the prospective randomized target temperature management trial, which found no benefit of targeting 33°C over 36°C in terms of outcome. Six-hundred eighty-two patients were included in the substudy. An admission ECG, which defined the present study population, was available in 602 patients (88%). These ECGs were stratified by the presence of LBBB, RBBB, or no-BBB (reference) on admission. End points were mortality and neurologic outcome 6 months after OHCA. RBBB was present in 79 patients (13%) and LBBB in 65 patients (11%), and the majority of BBBs (92%) had resolved 4 hours after admission. RBBB was associated with significantly higher 6 months mortality (RBBB: hazard ratio [HR]unadjusted 1.78, 95% confidence interval [CI] 1.30 to 2.43; LBBB: HRunadjusted 1.26, 95% CI 0.87 to 1.81), but this did not reach a level of significance in the adjusted model (HRadjusted 1.33, 95% CI 0.94 to 1.87). Similar findings were seen for neurologic outcome in the unadjusted and adjusted analyses. RBBB was further independently associated with higher odds of unfavorable neurologic outcome (RBBB: adjusted odds ratio 1.97, 95% CI 1.05 to 3.71). In conclusion, BBBs after OHCA were transient in most patients, and RBBB was directly associated with higher mortality and independently associated with higher odds of unfavorable neurologic outcome. RBBB is seemingly an early indicator of an unfavorable prognosis after OHCA.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Niklas Nielsen
- Department of Anesthesia and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden
| | - David Erlinge
- Department of Cardiology, Lund University Hospital, Lund, Sweden
| | - Sebastian Wiberg
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Michael Wanscher
- Department of Cardiothoracic Anesthesia, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - John Bro-Jeppesen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
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Tomoda H, Aoki N. Right Bundle Branch Block in Acute Myocardial Infarction Treated by Primary Coronary Angioplasty and Stenting. Angiology 2016; 56:131-6. [PMID: 15793601 DOI: 10.1177/000331970505600202] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with right bundle branch block (RBBB) in acute myocardial infarction (AMI) have a significantly higher mortality rate even with the advent of thrombolytic therapy. This study was undertaken to assess the impact of primary percutaneous transluminal coronary angioplasty (PTCA) and stenting on the outcome of patients with RBBB in AMI. A total of 600 patients with AMI who underwent primary PTCA and stenting (rate: 61%) <12 hours of onset were studied. A 12-lead ECG was obtained at least every 6 hours. Serial creatine kinase was measured, and left ventricular ejection fraction was obtained during the hospital stay. Among 600 patients with AMI, 94 patients (15.7%) had RBBB; it was persistent in 31 (33%) and transient in 63 (67%). In-hospital mortality rate was 7.3% in patients without RBBB, 7.9% in transient RBBB, and 25.8% in persistent RBBB (p<0.02). The incidence of heart failure was 26.5% in those without RBBB, 34.9% in transient RBBB, and 58.1% in persistent RBBB (p<0.001). There was no significant difference among these 3 groups in ventricular arrhythmias and complete atrioventricular block. Peak creatine kinase was 3,214 ±2,293 U/L in those without RBBB, 4,558 ±3,316 U/L in transient RBBB (p<0.001), and 5,635 ±3,920 U/L in persistent RBBB (p<0.001). Left ventricular ejection fraction was 50 ±11% in those without RBBB, 47 ±11% in transient RBBB (p<0.05), and 42 ±13% in persistent RBBB (p<0.001). Patients with AMI treated by primary PTCA and stenting had an increased incidence of transient RBBB, especially following reperfusion therapy, although the clinical outcome was similar to that of those without RBBB. In contrast, there was no satisfactory improvement in clinical outcomes in those with persistent RBBB.
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Affiliation(s)
- Haruo Tomoda
- Department of Cardiology, Tokai University Hospital, Kanagawa, Japan.
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Xiang L, Zhong A, You T, Chen J, Xu W, Shi M. Prognostic Significance of Right Bundle Branch Block for Patients with Acute Myocardial Infarction: A Systematic Review and Meta-Analysis. Med Sci Monit 2016; 22:998-1004. [PMID: 27017617 PMCID: PMC4811299 DOI: 10.12659/msm.895687] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background The aim of the current meta-analysis was to assess the effect of right bundle branch block (RBBB) on mortality outcome in patients with acute myocardial infarction (AMI). Material/Methods Embase, PubMed, and Cochrane databases were searched through January 2015 using the keywords “RBBB”, “mortality”, “AMI”, “Coronary Heart Disease”, and “cardiovascular”. An odds ratio (OR) of RBBB on mortality endpoints was calculated using random-effects models. Results RBBB was associated with significantly increased overall mortality in patients with AMI. The OR of RBBB for deaths was 1.56 [95% confidence interval (CI), 1.44 to 1.68, p<0.001]. Moreover, RBBB showed a considerable effect on both in-hospital mortality (OR: 1.94, 95% CI: 1.60 to 2.37, p=0.002) and long-term mortality (OR: 1.49, 95% CI: 1.37 to 1.62, p<0.001). Conclusions RBBB is associated with an increased risk of all-cause mortality and indicates a poorer prognosis in patients with AMI.
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Affiliation(s)
- Li Xiang
- Department of Cardiology, The Second Affiliated Hospital, Soochow University, Suzhou, Jiangsu, China (mainland)
| | - Anyuan Zhong
- Department of Respiration, The Second Affiliated Hospital, Soochow University, Suzhou, Jiangsu, China (mainland)
| | - Tao You
- Department of Cardiology, The Second Affiliated Hospital, Soochow University, Suzhou, Jiangsu, China (mainland)
| | - Jianchang Chen
- Department of Cardiology, The Second Affiliated Hospital, Soochow University, Suzhou, Jiangsu, China (mainland)
| | - Weiting Xu
- Department of Cardiology, The Second Affiliated Hospital, Soochow University, Suzhou, Jiangsu, China (mainland)
| | - Minhua Shi
- Department of Respiration, The Second Affiliated Hospital, Soochow University, Suzhou, Jiangsu, China (mainland)
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21
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Chan WK, Goodman SG, Brieger D, Fox KAA, Gale CP, Chew DP, Udell JA, Lopez-Sendon J, Huynh T, Yan RT, Singh SM, Yan AT. Clinical Characteristics, Management, and Outcomes of Acute Coronary Syndrome in Patients With Right Bundle Branch Block on Presentation. Am J Cardiol 2016; 117:754-9. [PMID: 26762726 DOI: 10.1016/j.amjcard.2015.12.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 12/01/2015] [Accepted: 12/01/2015] [Indexed: 12/22/2022]
Abstract
We examined the relations between right bundle branch block (RBBB) and clinical characteristics, management, and outcomes among a broad spectrum of patients with acute coronary syndrome (ACS). Admission electrocardiograms of patients enrolled in the Global Registry of Acute Coronary Events (GRACE) electrocardiogram substudy and the Canadian ACS Registry I were analyzed independently at a blinded core laboratory. We performed multivariable logistic regression analysis to assess the independent prognostic significance of admission RBBB on in-hospital and 6-month mortality. Of 11,830 eligible patients with ACS (mean age 65; 66% non-ST-elevation ACS), 5% had RBBB. RBBB on admission was associated with older age, male sex, more cardiovascular risk factors, worse Killip class, and higher GRACE risk score (all p <0.01). Patients with RBBB less frequently received in-hospital cardiac catheterization, coronary revascularization, or reperfusion therapy (all p <0.05). The RBBB group had higher unadjusted in-hospital (8.8% vs 3.8%, p <0.001) and 6-month mortality rates (15.1% vs 7.6%, p <0.001). After adjusting for established prognostic factors in the GRACE risk score, RBBB was a significant independent predictor of in-hospital death (odds ratio 1.45, 95% CI 1.02 to 2.07, p = 0.039), but not cumulative 6-month mortality (odds ratio 1.29, 95% CI 0.95 to 1.74, p = 0.098). There was no significant interaction between RBBB and the type of ACS for either in-hospital or 6-month mortality (both p >0.50). In conclusion, across a spectrum of ACS, RBBB was associated with preexisting cardiovascular disease, high-risk clinical features, fewer cardiac interventions, and worse unadjusted outcomes. After adjusting for components of the GRACE risk score, RBBB was a significant independent predictor of early mortality.
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Affiliation(s)
- William K Chan
- Terrence Donnelly Heart Centre, Department of Medicine, St Michael's Hospital, Toronto, Canada; University of Toronto, Toronto, Canada
| | - Shaun G Goodman
- Terrence Donnelly Heart Centre, Department of Medicine, St Michael's Hospital, Toronto, Canada; University of Toronto, Toronto, Canada; Canadian Heart Research Centre, Toronto, Canada
| | - David Brieger
- Coronary Care Unit, Concord Hospital, Sydney, Australia
| | - Keith A A Fox
- Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, United Kingdom
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Derek P Chew
- Department of Cardiovascular Medicine, Department of Cardiovascular Medicine Flinders University, Adelaide, South Australia, Australia
| | - Jacob A Udell
- University of Toronto, Toronto, Canada; Women's College Hospital, Toronto, Canada
| | | | - Thao Huynh
- McGill University Health Centre, McGill University, Montreal, Canada
| | | | - Sheldon M Singh
- University of Toronto, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Andrew T Yan
- Terrence Donnelly Heart Centre, Department of Medicine, St Michael's Hospital, Toronto, Canada; University of Toronto, Toronto, Canada.
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22
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Peteiro J, Bouzas-Mosquera A, Broullón J, Yañez J, Martinez D, Vazquez JM. Exercise left ventricular ejection fraction predicts events in right bundle branch block. SCAND CARDIOVASC J 2015; 50:108-13. [PMID: 26634337 DOI: 10.3109/14017431.2015.1118529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Interpretation of the electrocardiogram (ECG) during exercise is not easy in patients with right bundle branch block (RBBB). Also, the value of exercise echocardiography (ExE) for predicting outcome in them has not been addressed. We sought to assess its prognostic value in patients with RBBB and known/suspected coronary disease. DESIGN Retrospective analysis of data on 703 patients with RBBB who were submitted to a clinically-indicated ExE. The end points were overall mortality and combined myocardial infarction and cardiovascular mortality. RESULTS During follow-up (4.1 ± 4.5 years) there were 130 deaths and 108 combined events. Independent predictors of combined events were history of coronary artery disease (hazard ratio [HR] = 2.37, 95% Confidence Interval [CI] = 1.24-4.52, p = 0.009) resting wall motion score index (HR = 2.14, 95% CI = 1.12-4.10, p = 0.02), metabolic equivalents (HR = 0.89, 95% CI = 0.93-0.97, p = 0.007), Δ in double product with exercise (HR = 0.96, 95% CI = 0.92-1.00, p = 0.036) and Δ in left ventricular ejection fraction (LVEF) with exercise (HR = 0.97, 95% CI = 0.94-0.99, p = 0.01). Neither positive clinical nor ECG exercise testing was predictive. Combined event rates were 3.3% in patients with ΔLVEF > 5%, 4.7% in those with ΔLVEF between 1-5% and 8.2% in those with no increase (Δ < 1%). CONCLUSIONS A decrease in LVEF during exercise is predictive of serious events in patients with RBBB.
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Affiliation(s)
- Jesús Peteiro
- a Department of Cardiology , Complejo Hospitalario Universitario de A Coruña (CHUAC), Universidad de A Coruña e Instituto de Investigacion Biomedica de A Coruña (INIBIC) , A Coruña , Spain
| | - Alberto Bouzas-Mosquera
- a Department of Cardiology , Complejo Hospitalario Universitario de A Coruña (CHUAC), Universidad de A Coruña e Instituto de Investigacion Biomedica de A Coruña (INIBIC) , A Coruña , Spain
| | - Javier Broullón
- b Department of Information Technology , Complejo Hospitalario Universitario de A Coruña (CHUAC), Universidad de A Coruña e Instituto de Investigacion Biomedica de A Coruña (INIBIC) , A Coruña , Spain
| | - Juan Yañez
- a Department of Cardiology , Complejo Hospitalario Universitario de A Coruña (CHUAC), Universidad de A Coruña e Instituto de Investigacion Biomedica de A Coruña (INIBIC) , A Coruña , Spain
| | - Dolores Martinez
- a Department of Cardiology , Complejo Hospitalario Universitario de A Coruña (CHUAC), Universidad de A Coruña e Instituto de Investigacion Biomedica de A Coruña (INIBIC) , A Coruña , Spain
| | - Jose Manuel Vazquez
- a Department of Cardiology , Complejo Hospitalario Universitario de A Coruña (CHUAC), Universidad de A Coruña e Instituto de Investigacion Biomedica de A Coruña (INIBIC) , A Coruña , Spain
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Epstein AE. Complete Heart Block Complicating ST-Segment Elevation Myocardial Infarction Has Not Gone Away. JACC Clin Electrophysiol 2015; 1:539-541. [DOI: 10.1016/j.jacep.2015.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 09/11/2015] [Accepted: 09/17/2015] [Indexed: 10/22/2022]
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Xiong Y, Wang L, Liu W, Hankey GJ, Xu B, Wang S. The Prognostic Significance of Right Bundle Branch Block: A Meta-analysis of Prospective Cohort Studies. Clin Cardiol 2015; 38:604-13. [PMID: 26436874 DOI: 10.1002/clc.22454] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 08/08/2015] [Accepted: 08/13/2015] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The prognostic significance of right bundle branch block (RBBB) is inconsistent across studies. We aimed to assess the association between RBBB (in general population and patients with heart disease) and risk of all-cause mortality, cardiac death, acute myocardial infarction (MI), and heart failure (HF). HYPOTHESIS RBBB may be associated with increased risk of death. METHODS PubMed, EMBASE, and the Cochrane Library up to February 2015 were searched for prospective cohort studies that reported RBBB at baseline and all-cause mortality, cardiac death, MI, and HF at follow-up. A meta-analysis of published data was undertaken primarily by means of fixed-effects models. RESULTS Nineteen cohort studies including 201 437 participants were included with a mean follow-up period ranging from 1 to 246 months. For general population with RBBB, the pooled adjusted hazard ratio (HR) for all-cause mortality was 1.17 (95% confidence interval [CI]: 1.03-1.33) compared with no BBB. General population with RBBB had an increased risk of cardiac death (HR: 1.43, 95% CI: 1.17-1.74). For patients with RBBB and acute MI, the pooled risk ratio was 2.31 (95% CI: 2.13-2.49) for in-hospital mortality, 2.85 (95% CI: 2.46-3.30) for 30-day mortality, and 1.96 (95% CI: 1.59-2.42) for longer-term mortality. For acute HF patients, the pooled risk ratio of all-cause mortality was 1.11 (95% CI: 1.06-1.16), and for chronic HF patients it was 1.75 (95% CI: 1.38-2.22). CONCLUSIONS Right bundle branch block is associated with an increased risk of mortality in general population and patients with heart disease.
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Affiliation(s)
- Yunyun Xiong
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Lian Wang
- Department of Cardiology, Nanjing Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wenyan Liu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Graeme J Hankey
- School of Medicine and Pharmacology, The University of Western Australia, Perth, Western Australia, Australia
| | - Biao Xu
- Department of Cardiology, Nanjing Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Shang Wang
- Department of Cardiology, Nanjing Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
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Melgarejo-Moreno A, Galcerá-Tomás J, Consuegra-Sánchez L, Alonso-Fernández N, Díaz-Pastor Á, Escudero-García G, Jaulent-Huertas L, Vicente-Gilabert M, Galcerá-Jornet E, Padilla-Serrano A, de Gea-García J, Pinar-Bermudez E. Relation of New Permanent Right or Left Bundle Branch Block on Short- and Long-Term Mortality in Acute Myocardial Infarction Bundle Branch Block and Myocardial Infarction. Am J Cardiol 2015; 116:1003-9. [PMID: 26253998 DOI: 10.1016/j.amjcard.2015.07.019] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 07/03/2015] [Accepted: 07/03/2015] [Indexed: 11/29/2022]
Abstract
The aim of this study was to investigate the prognosis associated with bundle branch block (BBB) depending on location, time of appearance, and duration in patients with myocardial infarction (MI). From January 1998 to January 2008, we recruited 5,570 patients with acute MI. Thirty-day and 7-year all-cause mortality, according to BBB location, time of appearance, and duration were analyzed by multivariable analyses. BBB was present in 964 patients (17.3%); right BBB (RBBB) 10.6% and left BBB (LBBB) 6.7%. Overall mortality rate at 30 days was 13.2% (n = 738) and 7 years was 6.34 deaths per 100 patient-year. Both RBBB and LBBB were more frequently previous, 42.9% and 58.8%. Compared with non-BBB, all BBB groups showed higher prevalence of co-morbidities, especially rates of diabetes (49.0% vs 34.3%, p <0.001) and more often heart failure during hospitalization (54.5% vs 26.6%, p <0.001). Compared with RBBB, patients with LBBB had a higher prevalence of co-morbidities and a higher mortality, especially the new BBB, 30 days: 52.5% versus 31.6% and 7 years (incident rate): 27.2 versus 13.3 per 100 patient-year. New transient BBB had lower heart failure on admission (42.6% vs 58.3%, p = 0.008) and 30-day mortality (20.3% vs 69.6%, p <0.001) compared with permanent in both locations. New permanent RBBB was independently associated with 30-day (hazard ratio [HR] 2.01, 95% confidence interval [CI] 1.45 to 2.79) and 7-year mortality (HR 3.12, 95% CI 2.38 to 4.09). New-permanent LBBB was independently associated with 30-day (HR 2.15, 95% CI 1.47 to 3.15) and 7-year mortality (HR 2.91, 95% CI 2.08 to 4.08). In conclusion, in patients with acute MI, the appearance of a new BBB was independently associated with a higher 30-day and 7-year all-cause mortality.
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Affiliation(s)
| | - José Galcerá-Tomás
- Coronary Care Unit, Hospital Clínico Universitario Virgen de la Arrixaca de Murcia, Murcia, Spain
| | | | | | - Ángela Díaz-Pastor
- Cardiology Department, Hospital Universitario Santa Lucía de Cartagena, Murcia, Spain
| | | | | | - Marta Vicente-Gilabert
- Coronary Care Unit, Hospital Clínico Universitario Virgen de la Arrixaca de Murcia, Murcia, Spain
| | - Emilio Galcerá-Jornet
- Coronary Care Unit, Hospital Clínico Universitario Virgen de la Arrixaca de Murcia, Murcia, Spain
| | - Antonio Padilla-Serrano
- Coronary Care Unit, Hospital Clínico Universitario Virgen de la Arrixaca de Murcia, Murcia, Spain
| | - José de Gea-García
- Coronary Care Unit, Hospital Clínico Universitario Virgen de la Arrixaca de Murcia, Murcia, Spain
| | - Eduardo Pinar-Bermudez
- Coronary Care Unit, Hospital Clínico Universitario Virgen de la Arrixaca de Murcia, Murcia, Spain
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Littmann L, Fitts JR, Mollo MA, Goode AL. Transient resolution of chronic right bundle branch block in the acute phase of myocardial infarction. J Electrocardiol 2014; 48:272-4. [PMID: 25528274 DOI: 10.1016/j.jelectrocard.2014.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Laszlo Littmann
- Department of Internal Medicine, Carolinas Medical Center, Charlotte, NC; Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC.
| | - James R Fitts
- Department of Internal Medicine, Carolinas Medical Center, Charlotte, NC; Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC
| | - Michael A Mollo
- Department of Internal Medicine, Carolinas Medical Center, Charlotte, NC; Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC
| | - Andrea L Goode
- Department of Internal Medicine, Carolinas Medical Center, Charlotte, NC; Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC
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Association of long-term air pollution with ventricular conduction and repolarization abnormalities. Epidemiology 2012; 22:773-80. [PMID: 21918454 DOI: 10.1097/ede.0b013e31823061a9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Short-term exposure to air pollution may affect ventricular repolarization, but there is limited information on how long-term exposures might affect the surface ventricular electrocardiographic (ECG) abnormalities associated with cardiovascular events. We carried out a study to determine whether long-term air pollution exposure is associated with abnormalities of ventricular repolarization and conduction in adults without known cardiovascular disease. METHODS A total of 4783 participants free of clinical cardiovascular disease in the Multi-Ethnic Study of Atherosclerosis underwent 12-lead ECG examinations, cardiac-computed tomography, and calcium scoring, as well as estimation of air pollution exposure using a finely resolved spatiotemporal model to determine long-term average individual exposure to fine particulate matter (PM(2.5)) and proximity to major roadways. We assessed ventricular electrical abnormalities including presence of QT prolongation (Rautaharju QTrr criteria) and intraventricular conduction delay (QRS duration >120 milliseconds). We used logistic regression to determine the adjusted relationship between air pollution exposures and ECG abnormalities. RESULTS A 10-μg/m³ increase in estimated residential PM(2.5) was associated with an increased odds of prevalent QT prolongation (adjusted odds ratio [OR] = 1.6 [95% confidence interval (CI) = 1.2-2.2]) and intraventricular conduction delay (1.7 [1.0-2.6]), independent of coronary-artery calcium score. Living near major roadways was not associated with ventricular electrical abnormalities. No evidence of effect modification by traditional risk factors or study site was observed. CONCLUSIONS This study demonstrates an association between long-term exposure to air pollution and ventricular repolarization and conduction abnormalities in adults without clinical cardiovascular disease, independent of subclinical coronary arterial calcification.
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Widimský P, Šťásek J, Kala P, Rokyta R, Kuzmanov B, Hlinomaz O, Bělohlávek J, Malý M. Acute myocardial infarction due to the left main coronary artery occlusion: electrocardiograhic patterns, angiographic findings, revascularization and in-hospital outcomes. COR ET VASA 2012. [DOI: 10.1016/j.crvasa.2011.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Widimsky P, Rohác F, Stásek J, Kala P, Rokyta R, Kuzmanov B, Jakl M, Poloczek M, Kanovsky J, Bernat I, Hlinomaz O, Belohlávek J, Král A, Mrázek V, Grigorov V, Djambazov S, Petr R, Knot J, Bílková D, Fischerová M, Vondrák K, Maly M, Lorencová A. Primary angioplasty in acute myocardial infarction with right bundle branch block: should new onset right bundle branch block be added to future guidelines as an indication for reperfusion therapy? Eur Heart J 2012; 33:86-95. [PMID: 21890488 PMCID: PMC3249219 DOI: 10.1093/eurheartj/ehr291] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Revised: 06/25/2011] [Accepted: 07/25/2011] [Indexed: 11/18/2022] Open
Abstract
AIMS The current guidelines recommend reperfusion therapy in acute myocardial infarction (AMI) with ST-segment elevation or left bundle branch block (LBBB). Surprisingly, the right bundle branch block (RBBB) is not listed as an indication for reperfusion therapy. This study analysed patients with AMI presenting with RBBB [with or without left anterior hemiblock (LAH) or left posterior hemiblock (LPH)] and compared them with those presenting with LBBB or with other electrocardiographic (ECG) patterns. The aim was to describe angiographic patterns and primary angioplasty use in AMI patients with RBBB. METHODS AND RESULTS A cohort of 6742 patients with AMI admitted to eight participating hospitals was analysed. Baseline clinical characteristics, ECG patterns, coronary angiographic, and echocardiographic data were correlated with the reperfusion therapies used and with in-hospital outcomes. Right bundle branch block was present in 6.3% of AMI patients: 2.8% had RBBB alone, 3.2% had RBBB + LAH, and 0.3% had RBBB + LPH. TIMI flow 0 in the infarct-related artery was present in 51.7% of RBBB patients vs. 39.4% of LBBB patients (P = 0.023). Primary percutaneous coronary intervention (PCI) was performed in 80.1% of RBBB patients vs. 68.3% of LBBB patients (P< 0.001). In-hospital mortality of RBBB patients was similar to LBBB (14.3 vs. 13.1%, P = 0.661). Patients with new or presumably new blocks had the highest (LBBB 15.8% and RBBB 15.4%) incidence of cardiogenic shock from all ECG subgroups. Percutaneous coronary intervention was done more frequently (84.8%) in patients with new or presumably new RBBB when compared with other patients with blocks (old RBBB 66.0%, old LBBB 62.3%, new or presumably new LBBB 73.0%). In-hospital mortality was highest (18.8%) among patients presenting with new or presumably new RBBB, followed by new or presumably new LBBB (13.2%), old LBBB (10.1%), and old RBBB (6.4%). Among 35 patients with acute left main coronary artery occlusion, 26% presented with RBBB (mostly with LAH) on the admission ECG. CONCLUSION Acute myocardial infarction with RBBB is frequently caused by the complete occlusion of the infarct-related artery and is more frequently treated with primary PCI when compared with AMI + LBBB. In-hospital mortality of patients with AMI and RBBB is highest from all ECG presentations of AMI. Restoration of coronary flow by primary PCI may lead to resolution of the conduction delay on the discharge ECG. Right bundle branch block should strongly be considered for listing in future guidelines as a standard indication for reperfusion therapy, in the same way as LBBB.
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Affiliation(s)
- Petr Widimsky
- Cardiology Department, Third Faculty of Medicine, Charles University Prague, University Hospital Kralovske Vinohrady, Srobarova 50, Prague 10, Czech Republic.
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Long-term cardiovascular outcomes in patients with angina pectoris presenting with bundle branch block. Am J Cardiol 2011; 107:1565-70. [PMID: 21439535 DOI: 10.1016/j.amjcard.2011.01.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2010] [Revised: 01/18/2011] [Accepted: 01/18/2011] [Indexed: 01/11/2023]
Abstract
Long-term outcomes of unselected patients with angina pectoris and bundle branch block (BBB) on initial electrocardiogram are not well established. The Olmsted County Chest Pain Study is a community-based cohort of 2,271 consecutive patients presenting to 3 Olmsted County emergency departments with angina from 1985 through 1992. Patients were followed for major adverse cardiovascular events (MACEs) including death, myocardial infarction, stroke, and revascularization at 30 days and over a median follow-up period of 7.3 years and for mortality only through a median of 16.6 years. Cox models were used to estimate associations between BBB and cardiovascular outcomes. Mean age of the cohort on presentation was 63 years, and 58% were men. MACEs at 30 days occurred in 11% with right BBB (RBBB), 8.8% with left BBB (LBBB), and 6.4% in patients without BBB (p = 0.17). Over a median follow-up of 7.3 years, patients with BBB were at higher risk for MACEs (RBBB, hazard ratio [HR] 1.85, 95% confidence interval [CI] 1.44 to 2.38, p <0.001; LBBB, HR 2.04, 95% CI 1.62 to 2.56, p <0.001) compared to those without BBB. Over a median of 16.6 years, the 2 BBB groups had lower survival rates than patients without BBB (RBBB, HR 2.19, 95% CI 1.73 to 2.78, p <0.001; LBBB, HR 3.32, 95% CI 2.67 to 4.13, p ≤0.001), but after adjustment for multiple risk factors an increased risk of mortality for LBBB remained significant. In conclusion, appearance of LBBB or RBBB in patients presenting with angina predicts adverse long-term cardiovascular outcomes compared to patients without BBB.
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Hypertrophies and intraventricular conduction defects: causes, presentation, and significance. Dimens Crit Care Nurs 2011; 29:259-75. [PMID: 20940577 DOI: 10.1097/dcc.0b013e3181f0be8d] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
There is an increasing need for nurses to interpret a 12-lead electrocardiogram, both in critical care units and in other areas. This can be a challenging task, especially in the presence of hypertrophies, bundle-branch blocks, and fascicular blocks. This article reviews the pathophysiology of intraventricular blocks and hypertrophy, characteristics found in the 12-lead electrocardiogram, and discusses what the significance of these findings may be.
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The incidence of right bundle branch block in acute myocardial infarction. COR ET VASA 2010. [DOI: 10.33678/cor.2010.211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Vivas D, Alfonso F. Bundle branch block during primary angioplasty: reperfusion success remains encrypted in the ECG! Interv Cardiol 2010. [DOI: 10.2217/ica.10.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Vivas D, Pérez-Vizcayno MJ, Hernández-Antolín R, Fernández-Ortiz A, Bañuelos C, Escaned J, Jiménez-Quevedo P, De Agustín JA, Núñez-Gil I, González-Ferrer JJ, Macaya C, Alfonso F. Prognostic implications of bundle branch block in patients undergoing primary coronary angioplasty in the stent era. Am J Cardiol 2010; 105:1276-83. [PMID: 20403479 DOI: 10.1016/j.amjcard.2009.12.044] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 12/14/2009] [Accepted: 12/14/2009] [Indexed: 10/19/2022]
Abstract
The presence of bundle branch block (BBB) in patients with ST-segment elevation myocardial infarction has been associated with a poor outcome. However, the implications of BBB in patients undergoing primary angioplasty in the stent era are poorly established. Furthermore, the prognostic implications of BBB type (right vs left and previous vs transient or persistent) remain unknown. We analyzed the data from 913 consecutive patients with ST-segment elevation myocardial infarction treated with primary angioplasty. All clinical, electrocardiographic, and angiographic data were prospectively collected. The median follow-up period was 19 months. The primary end point was the combined outcome of death and reinfarction. BBB was documented in 140 patients (15%). Right BBB (RBBB) was present in 119 patients (13%) and was previous in 27 (23%), persistent in 45 (38%), and transient in 47 (39%). Left BBB (LBBB) was present in 21 patients (2%) and was previous in 8 (38%), persistent in 9 (43%), and transient in 4 (19%). Patients with BBB were older, and more frequently had diabetes, anterior infarctions, a greater Killip class, a lower left ventricular ejection fraction, and greater mortality (all p <0.005) than patients without BBB. The short- and long-term primary outcome occurred more frequently in patients with persistent RBBB/LBBB than in those with previous or transient RBBB/LBBB. On multivariate analysis, persistent RBBB/LBBB emerged as an independent predictor of death and reinfarction. In conclusion, in patients undergoing primary angioplasty in the stent era, BBB is associated with poor short- and long-term prognosis. This risk appears to be particularly high among patients with persistent BBB.
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Baslaib F, Alkaabi S, Yan AT, Yan RT, Dorian P, Nanthakumar K, Casanova A, Goodman SG. QRS prolongation in patients with acute coronary syndromes. Am Heart J 2010; 159:593-8. [PMID: 20362717 DOI: 10.1016/j.ahj.2010.01.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2009] [Accepted: 01/14/2010] [Indexed: 12/22/2022]
Abstract
BACKGROUND QRS prolongation with or without bundle branch block (BBB) has been associated with adverse outcome in myocardial infarction; we examined the relationship between QRS duration and outcome in a broad spectrum of patients with acute coronary syndrome (ACS). METHOD AND RESULTS Core laboratory evaluation of the presenting electrocardiogram in Canadian ACS Registry patients (n = 5,003) showed 4,289 (85.7%) had QRS <120 milliseconds, 202 (4.0%) patients had QRS > or =120 milliseconds without BBB, 262 (5.2%) had left BBB (LBBB), and 250 (5.0%) had right BBB. Compared to patients with QRS <120 milliseconds, patients with QRS > or =120 milliseconds without BBB had higher in-hospital (3.5% vs 1.9%, odds ratio [OR] 1.87, 95% CI 0.85-4.09, P = .12) and 1-year mortality (14.9% vs 7.7%, OR 2.10, 95% CI 1.38-3.18, P = .001). In-hospital and 1-year mortality was significantly higher in patients with BBB (eg, LBBB compared with QRS <120 milliseconds) (5.0% vs 1.9%, OR 2.71, 95% CI 1.49-4.94, P = .001, and 23.8% vs 7.7%, OR 3.74, 95% CI 2.72-5.13, P < .001). Analyzed as a continuous variable and after adjustment for validated prognosticators, QRS duration was an independent predictor of 1-year death (OR 1.11, 95% CI 1.06-1.16, P < .001) and death/myocardial infarction (OR 1.06, 95% CI 1.02-1.11, P = .003). However, when using clinically applicable QRS duration evaluation, only LBBB was an independent predictor of 1-year mortality (OR 1.93, 95% CI 1.28-2.90, P = .002). CONCLUSIONS In patients presenting with a broad spectrum of suspected ACS, QRS prolongation-particularly in the setting of LBBB-is an independent predictor of in-hospital and 1-year mortality.
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Right bundle-branch block in acute coronary syndrome: diagnostic and therapeutic implications for the emergency physician. Am J Emerg Med 2010; 27:1130-41. [PMID: 19931763 DOI: 10.1016/j.ajem.2008.09.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Accepted: 09/23/2008] [Indexed: 11/21/2022] Open
Abstract
Right bundle-branch block (RBBB) in the patient with acute coronary syndrome is a marker of significant potential cardiovascular risk; the RBBB pattern in the patient with acute coronary syndrome identifies a subgroup of patients with quite high short- and long-term morbidity and mortality. Right bundle-branch block is not an uncommon finding on an electrocardiogram in the emergency department patient, noted incidentally and thus without clinical import or, conversely, encountered in the early phase of significant cardiovascular dysfunction. This review will address RBBB in the acute coronary syndrome setting.
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The importance of right bundle branch block in myocardial infarction. COR ET VASA 2009. [DOI: 10.33678/cor.2009.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Sugiura T, Yamasaki F, Hatada K, Nakamura S, Iwasaka T. Correlates of bundle-branch block in patients undergoing primary angioplasty for acute myocardial infarction. Clin Cardiol 2009; 24:770-4. [PMID: 11768740 PMCID: PMC6655111 DOI: 10.1002/clc.4960241204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Early reperfusion therapy has reduced the infarct size and mortality rate in patients with acute myocardial infarction (AMI). The occurrence of bundle-branch block in AMI is related to the amount of myocardial damage and the insult to the conduction system. HYPOTHESIS To evaluate the clinical and angiographic factors related to the occurrence of bundle-branch block (BBB) in patients with primary percutaneous transluminal coronary angioplasty (PTCA), we investigated consecutive series of patients with their first Q-wave AMI and successful PTCA. METHODS Coronary angiogram at the time of admission, electrocardiogram, and echocardiogram were evaluated in 279 patients with their first Q-wave AMI and successful PTCA. RESULTS Bundle-branch block was detected in 26 patients (9%); 16 patients had transient and 10 patients had persistent block, while 16 patients had bifascicular block and 10 patients had right BBB. The patients with BBB had a significantly larger number of left ventricular asynergic segments, higher incidence of total occlusion of infarct-related artery, angiographic no reflow, and pericardial rub than those without BBB. When the multivariate analysis was performed using five clinical markers of infarct severity, angiographic no reflow (F = 20.2, p < 0.001) and total occlusion of infarct-re-lated artery (F = 4.2, p = 0.04) were found to be the significant variables related to BBB. CONCLUSIONS Despite successful primary PTCA, absence of antegrade flow in the infarct-related artery at the onset of AMI and/or angiographic no reflow resulted in more severe transmural myocardial damage and, hence, the occurrence of BBB.
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Affiliation(s)
- T Sugiura
- Department of Clinical Laboratory Medicine, Kochi Medical School, Japan
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Melgarejo-Moreno A, Galcerá-Tomás J, Garcia-Alberola A. Prognostic significance of bundle-branch block in acute myocardial infarction: the importance of location and time of appearance. Clin Cardiol 2009; 24:371-6. [PMID: 11346244 PMCID: PMC6655020 DOI: 10.1002/clc.4960240505] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The presence of bundle-branch block (BBB) is associated with high mortality rates and is considered an important predictor of poor outcome in patients with acute myocardial infarction (AMI). HYPOTHESIS The objective of this study was to assess the prognostic significance of BBB in patients with AMI depending on its form of presentation. METHODS A multicenter prospective 1-year follow-up study involving 1,239 consecutive patients diagnosed with AMI was performed. RESULTS Bundle-branch block was present in 177 cases (14.2%), associated with worse clinical characteristics, lower rate of thrombolytic therapy, and higher mortality: in-hospital (23.8 vs. 9.7%, p < .01) and 1-year (40.9 vs. 16.9%, p < 0.01). Compared with right BBB (n = 135), left BBB (n = 42) was more often associated with female gender and higher prevalence of cardiovascular diseases, but had a similar 1-year mortality. In the absence of heart failure or complete atrioventricular (AV) block, there was no difference in in-hospital mortality of patients with BBB (n = 76) and without BBB (n = 786) (2.6 vs. 3.9%). Compared with existing BBB (n = 113), BBB of new appearance (n = 64) was more often accompanied by complete AV block and heart failure and higher in-hospital and 1-year mortality rates. Only BBB of new appearance was an independent predictor of mortality: in-hospital (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.1-4.7) and 1-year mortality (OR 3.2, 95% CI, 1.7-9.1). CONCLUSIONS In patients with AMI, the classification of BBB according not only to location but also to time of appearance is of practical interest. New BBB is an independent predictor of short- and long-term mortality.
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Kleemann T, Juenger C, Gitt AK, Schiele R, Schneider S, Senges J, Darius H, Seidl K. Incidence and clinical impact of right bundle branch block in patients with acute myocardial infarction: ST elevation myocardial infarction versus non-ST elevation myocardial infarction. Am Heart J 2008; 156:256-61. [PMID: 18657654 DOI: 10.1016/j.ahj.2008.03.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2007] [Accepted: 03/04/2008] [Indexed: 11/17/2022]
Abstract
BACKGROUND Both left bundle branch block and right bundle branch block (RBBB) have been associated with increased inhospital and long-term mortality in patients with acute ST elevation myocardial infarction (STEMI). However, the prognostic role of RBBB in acute non-ST elevation myocardial infarction (NSTEMI) is not well known. Therefore, the aim of the study was to evaluate the incidence and clinical impact of RBBB in patients with NSTEMI compared to patients with STEMI. METHODS From the German prospective multicenter registry "Maximal Individual Therapy of Acute Myocardial Infarction" (MITRA PLUS), 6,403 consecutive patients with NSTEMI and 20,233 patients with STEMI were analyzed. Patients with left bundle branch block were excluded. The median follow-up time for NSTEMI was 378 days and for STEMI 479 days. RESULTS A total of 455 (7.1%) patients with NSTEMI and 894 (4.4%) patients with STEMI presented with RBBB on admission. In general, RBBB patients were older, more often had comorbidities, and less often received short-term inhospital treatment according to guidelines. In STEMI, RBBB patients had higher peak enzyme levels and lower left ventricular ejection fraction (LV-EF) than patients without BBB. Right bundle branch block in STEMI was associated with an increased inhospital and long-term mortality. In NSTEMI, however, peak enzyme levels and LV-EF were similar in both groups with and without RBBB. Right bundle branch block in NSTEMI was not independently associated with a worse outcome. CONCLUSIONS Unlike RBBB in STEMI, RBBB in NSTEMI is not an independent predictor of inhospital and long-term mortality.
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Affiliation(s)
- Thomas Kleemann
- Herzzentrum Ludwigshafen, Institut für Herzinfarktforschung Ludwigshafen an der Universität Heidelberg, Ludwigshafen, Germany.
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Sakakura K, Kubo N, Hashimoto S, Ikeda N, Funayama H, Hirahara T, Sugawara Y, Yasu T, Ako J, Kawakami M, Momomura SI. Determinants of in-hospital death in left main coronary artery myocardial infarction complicated by cardiogenic shock. J Cardiol 2008; 52:24-9. [PMID: 18639774 DOI: 10.1016/j.jjcc.2008.03.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2008] [Revised: 02/17/2008] [Accepted: 03/18/2008] [Indexed: 12/24/2022]
Abstract
BACKGROUND Acute myocardial infarction (AMI) due to left main coronary artery disease is associated with significantly elevated morbidity and mortality. The aim of this study was to identify the predictors of in-hospital death from left main AMI complicated by cardiogenic shock. METHODS Clinical record review identified a total of 25 cases of left main AMI with cardiogenic shock. Patients' background characteristics, laboratory data, and angiographic findings were analyzed according to the in-hospital mortality. RESULTS In this patient subset, in-hospital mortality (60%) was associated with a history of hypertension (p=0.02) and a higher heart rate (p=0.02). Furthermore, in-hospital mortality was also associated with a complete right bundle branch block (CRBBB) pattern in the admission ECG (p=0.01) and low HCO(3)(-) (p=0.0004). In stepwise logistic regression analysis, a CRBBB pattern (OR 48.59, 95% CI 1.34-1768.10, p=0.03) and low HCO(3)(-) (OR 0.62, 95% CI 0.40-0.94, p=0.02) were found to be independent predictors of mortality. CONCLUSIONS Left main AMI with cardiogenic shock was associated with high in-hospital mortality. A CRBBB pattern in the ECG on admission and a low HCO(3)(-) concentration were significant independent predictors of in-hospital death.
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Affiliation(s)
- Kenichi Sakakura
- Division of Cardiovascular Medicine, Department of Integrated Medicine I, Jichi Medical University Saitama Medical Center, Omiya, Japan
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Attar MN, Wong K, Groves DG, Newall N, Ramsdale DR, Moore RK. Clinical implications of QRS duration and QT peak prolongation in patients with suspected coronary disease referred for elective cardiac catheterization. Ann Noninvasive Electrocardiol 2008; 13:106-12. [PMID: 18426435 DOI: 10.1111/j.1542-474x.2008.00209.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The electrocardiogram (ECG) remains a simple, universally available, and prognostically powerful investigation in heart failure, and acute coronary syndromes. We sought to assess the prognostic utility of clinical, angiographic, and simple ECG parameters in a large cohort of patients undergoing elective cardiac catheterization (CC) for known or suspected coronary artery disease. METHODS Consecutive consenting patients undergoing CC for coronary disease were enrolled at a single tertiary center. Patient data, drug therapy, catheter reports, and ECG recordings were prospectively recorded in a validated electronic archive. The primary outcome measure was death or nonfatal myocardial infarction (MI) over 1 year or until percutaneous or cardiac surgical intervention. Independent prognostic markers were identified using the Cox proportional hazard model. RESULTS A total of 682 individuals were recruited of whom 17(2.5%) died or suffered a nonfatal MI in 1 year. In multivariate analysis QRS duration (ms) (HR 1.03 95% CI 1.01-1.05, P = 0.003), extent of coronary disease (HR 2.01 95% CI 1.24-3.58, P = 0.006), and prolonged corrected QT peak interval in lead I (HR 1.02 95% CI 1.00-1.03, P = 0.044) were independently associated with death or nonfatal MI. Receiver-operator characteristic (ROC) analysis for the multivariate model against the primary end point yielded an area under the curve of 0.759 (95% CI 0.660-0.858), P < 0.001. CONCLUSIONS QRS duration and QT peak are independently associated with increased risk of death or nonfatal MI in stable patients attending for coronary angiography.
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Kurisu S, Inoue I, Kawagoe T, Ishihara M, Shimatani Y, Hata T, Nakama Y, Kijima Y, Kagawa E. Right bundle-branch block in anterior acute myocardial infarction in the coronary intervention era: Acute angiographic findings and prognosis. Int J Cardiol 2007; 116:57-61. [PMID: 16815572 DOI: 10.1016/j.ijcard.2006.02.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2005] [Revised: 02/11/2006] [Accepted: 02/24/2006] [Indexed: 11/21/2022]
Abstract
BACKGROUND Previous studies in the prethrombolytic or thrombolytic era have reported that right bundle-branch block (RBBB) is associated with poor clinical outcome in patients with acute myocardial infarction (AMI). METHODS AND RESULTS The purpose of this study was to examine the relations between RBBB and angiographic findings or clinical outcomes in patients with AMI in the coronary intervention era. A total of 430 patients with a first anterior AMI who underwent coronary angiography within 12 h after the onset were enrolled in this study. Seventy-one patients (17%) had RBBB documented during their hospital stay. RBBB was documented on admission in 35 patients. Patients with RBBB were older (p<0.01) and had prodromal angina less frequently (p=0.03) than those without. On the initial angiograms, patients with RBBB had an occluded left anterior descending artery (p<0.01) and multivessel disease (p=0.01) more frequently than those without. Thirty-day mortality rate was significantly higher in patients with RBBB than in those without (14.0% vs 1.9%, p<0.01). Multiple logistic-regression analysis demonstrated that RBBB (odds ratio 5.89, p<0.01) and multivessel disease (odds ratio 4.36, p=0.01) were independent predictors of 30-day mortality. CONCLUSIONS Our data suggested that RBBB was still associated with poor clinical outcome in patients with anterior AMI even in the coronary intervention era.
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Affiliation(s)
- Satoshi Kurisu
- Department of Cardiology, Hiroshima City Hospital, 7-33, Moto-machi, Naka-ku, Hiroshima, 730-8518 Japan.
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Marcus GM, Hoang KL, Hunt SA, Chun SH, Lee BK. Prevalence, patterns of development, and prognosis of right bundle branch block in heart transplant recipients. Am J Cardiol 2006; 98:1288-90. [PMID: 17056348 DOI: 10.1016/j.amjcard.2006.06.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2006] [Revised: 06/07/2006] [Accepted: 06/07/2006] [Indexed: 11/17/2022]
Abstract
Right bundle branch block (RBBB) is the most common electrocardiographic abnormality in heart transplant recipients, but the cause remains unknown, data regarding the prognosis are conflicting, and all previous studies have been limited to <100 patients. This was a study of patients who underwent heart transplantation at Stanford University Medical Center from 1981 to 1995 with known outcomes and >or=2 available electrocardiograms (ECGs). Outcomes were assessed in those with and without conduction disturbances recorded from the ECGs closest to the time of transplantation and the most recent ECGs. Of the 322 heart transplant recipients studied, 141 (44%) died over a mean follow-up of 9 +/- 3.5 years, and 40 (13%) died of sudden cardiac death. In the first ECG obtained, a mean of 1.8 +/- 2.4 years after transplantation, 44 patients (14%) had incomplete RBBB and 26 (8%) had RBBB; in the second ECG, obtained a mean of 5.6 +/- 3.7 years after transplantation, 59 patients (18%) had incomplete RBBB and 63 (20%) had RBBB. Increasing time from transplantation was associated with a greater likelihood for RBBB on the first and second ECGs (p = 0.001 and p <0.0001, respectively). QRS duration, incomplete RBBB, RBBB, or the development of RBBB was not associated with mortality or sudden cardiac death. In conclusion, although RBBB was the most common electrocardiographic abnormality in our study, the prevalence was lower than previously reported. The cause of RBBB appears to be largely related to events that occur well after transplantation, and the prognosis is benign.
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Affiliation(s)
- Gregory M Marcus
- Division of Cardiology, Electrophysiology Section, University of California, San Francisco, San Francisco, California, USA.
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Savonitto S, Fusco R, Granger CB, Cohen MG, Thompson TD, Ardissino D, Califf RM. Clinical, electrocardiographic, and biochemical data for immediate risk stratification in acute coronary syndromes. Ann Noninvasive Electrocardiol 2006; 6:64-77. [PMID: 11174865 PMCID: PMC7027624 DOI: 10.1111/j.1542-474x.2001.tb00088.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The recent evolution in therapeutic options for acute coronary syndromes (ACS) mandates early risk stratification in order to select the appropriate treatment strategy for individual patients. Simple clinical data derived from the patient's medical history and physical examination, a standard twelve-lead electrocardiogram (ECG), and determinations of biochemical markers of myocardial damage can be obtained in the emergency room and serve as a guide for deciding appropriate medical management and optimal use of available resources. Even the most important classification of the ACS is based upon a simple and dichotomous description of the ECG, where the presence of ST-segment elevation mandates an immediate attempt to restore coronary perfusion (either pharmacologically or mechanically), whereas its absence suggests pharmacological stabilization before further evaluation. Across the whole spectrum of ACS, clinical history data (such as older age, previous coronary events, and diabetes) and clinical variables (such as higher heart rate, lower blood pressure, and higher Killip class) are the most powerful prognostic determinants at multivariate analyses derived from large databases. The ECG adds significant and independent prognostic information using the analysis of qualitative (direction of ST-segment shift, associated T-wave inversion, and presence of conduction disturbances) and quantitative (number of leads involved, amount of ST- segment shifts, duration of QRS) characteristics. Biochemical markers of myocardial damage have also been identified as independent predictors of events. In addition, retrospective analyses of clinical trials have suggested that biochemical markers might serve as a guide to select pharmacological therapy. However, how to best combine electrocardiographic and biochemical data for immediate risk stratification remains to be further elucidated.
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Affiliation(s)
- S Savonitto
- Dipartment of Cardiology Angelo De Gasperis, Niguarda Ca' Granda Hospital, Milan, Italy.
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Fesmire FM, Brady WJ, Hahn S, Decker WW, Diercks DB, Ghaemmaghami CA, Nazarian D, Jagoda AS. Clinical policy: indications for reperfusion therapy in emergency department patients with suspected acute myocardial infarction. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Reperfusion Therapy in Emergency Department Patients with Suspected Acute Myocardial Infarction. Ann Emerg Med 2006; 48:358-83. [PMID: 16997672 DOI: 10.1016/j.annemergmed.2006.07.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Suzuki M, Sakaue T, Tanaka M, Hirose E, Saeki H, Matsunaka T, Hiramatsu S, Kazatani Y. Association Between Right Bundle Branch Block and Impaired Myocardial Tissue-Level Reperfusion in Patients With Acute Myocardial Infarction. J Am Coll Cardiol 2006; 47:2122-4. [PMID: 16697336 DOI: 10.1016/j.jacc.2006.02.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Bauer A, Watanabe MA, Barthel P, Schneider R, Ulm K, Schmidt G. QRS duration and late mortality in unselected post-infarction patients of the revascularization era. Eur Heart J 2005; 27:427-33. [PMID: 16338936 DOI: 10.1093/eurheartj/ehi683] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS To assess the association of prolonged QRS duration and late mortality in unselected post-infarction patients of the revascularization era. METHODS AND RESULTS A total of 1455 survivors of acute myocardial infarction (MI) in sinus rhythm and under 76 years of age were enrolled. Ninety eight percent of the patients received reperfusion/revascularization therapy (90% percutaneous coronary intervention). After revascularization, prolonged QRS duration (>or=120 ms) was present in 87 patients (6.0%). Additional risk factors studied were age (>or=65 years), presence of diabetes mellitus, history of previous MI, mean heart rate (>75 b.p.m.), heart rate variability index (<or=20 U), arrhythmia on Holter, left ventricular ejection fraction (LVEF<or=30%), and heart rate turbulence (HRT). Primary endpoint was total mortality. During a follow-up period of 22+/-5 months, 70 patients died. On multivariable analysis, prolonged QRS duration showed the highest association with total mortality (hazard ratio 4.0; CI 2.3-6.9) followed by HRT Category 2 (3.8; 2.0-7.3) and LVEF<or=30% (3.1; 1.7-5.6). The association of prolonged QRS duration and late mortality was particularly strong in patients with LVEF<or=30% (5.0; 1.8-14.1). On multivariable analysis of secondary endpoints, prolonged QRS duration was significantly associated with cardiac mortality (3.9; 1.9-7.8), but not with sudden death and serious arrhythmic events. CONCLUSION In the revascularization era, incidence of prolonged QRS duration is reduced. However, prolonged QRS duration is still highly correlated with increased late mortality.
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Affiliation(s)
- Axel Bauer
- Medizinische Klinik der Technischen Universität München and Deutsches Herzzentrum München, Ismaninger Strasse 22, 81675 München, Germany
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Wong CK, Stewart RAH, Gao W, French JK, Raffel C, White HD. Prognostic differences between different types of bundle branch block during the early phase of acute myocardial infarction: insights from the Hirulog and Early Reperfusion or Occlusion (HERO)-2 trial. Eur Heart J 2005; 27:21-8. [PMID: 16269419 DOI: 10.1093/eurheartj/ehi622] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS Bundle branch block (BBB) early during acute myocardial infarction (AMI) is often considered high risk for mortality. Little is known about how different BBB types influence prognosis. METHODS AND RESULTS The HERO-2 trial recruited 17 073 patients with ischaemic symptoms lasting >30 min and either ST elevation with or without right bundle branch block (RBBB) or presumed-new left bundle branch block (LBBB). Electrocardiograms were performed before and 60 min after the start of fibrinolytic therapy. Using patients with normal intraventricular conduction as a reference, odds ratios (ORs) for 30-day mortality were calculated for different BBB types (LBBB, RBBB with anterior AMI, and RBBB with inferior AMI) present at randomization and/or 60 min, with adjustment for recruitment region, pre-infarction characteristics, time to randomization, hemodynamics, and Killip class. At randomization, the 873 patients (5.11%) with BBB had worse baseline characteristics than patients without BBB. In patients presenting with LBBB (n=300), the ORs for 30-day mortality were 1.90 (95% CI 1.39-2.59) before and 0.68 (0.48-0.99) after adjustment for other prognosticators. In patients presenting with RBBB (n=415) and anterior AMI, the ORs were 3.52 (2.82-4.38) before and 2.48 (1.93-3.19) after adjustment. In patients presenting with RBBB and inferior AMI (n=158), the ORs were 1.74 (1.06-2.86) before and 1.22 (0.71-2.08) after adjustment. Within 60 min, 143 patients (0.92%) developed new BBB. The adjusted ORs for 30-day mortality were 2.97 (1.16-7.57) in the 25 patients with new LBBB, 3.84 (2.38-6.22) in the 100 with new RBBB and anterior AMI, and 2.23 (0.54-9.21) in the 18 with new RBBB and inferior AMI. CONCLUSION RBBB accompanying anterior AMI at presentation and new BBB (including LBBB) early after fibrinolytic therapy are independent predictors of high 30-day mortality. These electrocardiographic features should be considered in risk stratification to identify high-risk patients.
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Affiliation(s)
- Cheuk-Kit Wong
- Cardiovascular Research Unit, Green Lane Cardiovascular Service, Auckland City Hospital, Private Bag 92024, Auckland 1030, New Zealand
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Di Chiara A. Right bundle branch block during the acute phase of myocardial infarction: modern redefinitions of old concepts. Eur Heart J 2005; 27:1-2. [PMID: 16269420 DOI: 10.1093/eurheartj/ehi552] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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